| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1999 |
|
231 |
203 |
$3K |
| D1110 |
Prophylaxis - adult |
139 |
123 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
105 |
$1K |
| D0272 |
Bitewings - two radiographic images |
111 |
97 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
170 |
111 |
$796.49 |
| D0220 |
Intraoral - periapical first radiographic image |
148 |
129 |
$703.74 |
| D0120 |
Periodic oral evaluation - established patient |
42 |
30 |
$522.32 |
| D1120 |
Prophylaxis - child |
17 |
16 |
$320.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
36 |
$310.60 |
| D0140 |
Limited oral evaluation - problem focused |
15 |
13 |
$269.82 |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
13 |
$60.00 |